In an era when lung cancer remains the most lethal cancer, accounting for more deaths than colon, breast and prostate cancer combined -- and surgery, when possible, is the most effective treatment -- Mayo Clinic surgeons have proposed a system of lung surgery quality indicators for surgeons and the public as a method to demonstrate best practices for obtaining positive patient outcomes.

Mayo Clinic surgeons believe the process is necessary because no other method currently exists to measure the quality of care received by patients undergoing lung surgery.

Death rates following surgery are reported. However, because they aren't adjusted for factors such as patient age and disease severity, they don't tell the whole story. To overcome this lack of risk adjustment in death rate data, the Mayo Clinic team proposed patient-centered processes that should occur prior to, during and after surgery to assure the likelihood of best surgical outcomes.

"There are certain processes that we can measure and report that clearly indicate whether a patient has received high-quality care around the time of their lung operation," explains Stephen Cassivi, M.D., Mayo Clinic thoracic surgeon. Dr. Cassivi presented a list of proposed patient-centered quality indicators for lung surgery at the 43rd Annual Meeting of the Society of Thoracic Surgeons this week in San Diego. "Knowing this data can help the patient decide about the care they are about to receive and where to go to receive that care -- and equally important, this knowledge can help chest surgery programs improve their quality of care by concentrating on identified weaknesses," says Dr. Cassivi. "Creating standards through measures of process will allow for directed quality improvement initiatives across all surgical centers."

The Mayo Clinic List of Quality Indicators

To find the clearest and most meaningful measures to evaluate lung surgery quality, the Mayo Clinic team analyzed the care of 606 lung surgery patients who underwent 628 lung surgeries at Mayo Clinic during one year. The patients' average age was 65.8 years and ranged from 2 to 93 years.

From the analysis, the following list emerged for processes that should occur prior to surgery because of their potential contribution to positive patient outcomes.

-- Pulmonary function testing

-- Electrocardiogram

-- Smoking history documented

-- Smoking cessation therapy offered to those patients still smoking prior to surgery

-- Appropriate preoperative staging of cancer

In addition, the Mayo Clinic team identified post-lung surgery practices that improve patient outcome. These include: use of incentive spirometry -- a simple breathing exercise meant to increase lung capacity and prevent postoperative pneumonia; timely response to heart rhythm disturbances; defined measures to prevent venous clots (deep vein thrombosis); documented timely attention to pain control for patients' comfort; and follow-up care planning with the patient prior to discharge from the hospital.

"All of these measures are patient-centered and relevant to the clinical improvement of the patient undergoing lung surgery, and they can be easily documented and assessed," Dr. Cassivi says. The Mayo Clinic thoracic surgery team suggests that surgeons and hospitals adopt them as standard protocol.

The Next Step

Mayo Clinic will work to formalize its proposal with the Society of Thoracic Surgeons. Adopting these quality process measures as standards and compiling data regarding adherence to these standards could be accomplished using the Society of Thoracic Surgeons national general thoracic surgery database.

Says Dr. Cassivi: "Our Mayo Clinic experience shows that if the whole general thoracic surgery team -- from surgeons, to nurses, nurse educators, physician assistants, physical therapists -- uses these process measures as indicators of a high quality of care, areas for improvement can be identified and improved in a timely fashion. If all practices used these indicators, the huge variability in care of lung surgery patients could be reduced and overall quality increased."

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